Hello, Dutch1955-ga!
Thank you for your very interesting question. As I’ve researched this
question, I’ve realized that this occurs more frequently than many may
want to believe. I viewed all of the results that returned from my
searches and chose to include the most interesting and/or pertinent
ones. You specifically asked about abdominal pain, so I have included
the best case reports available. Using my original search terms, I
encountered a number of case studies and reports of surgical sponges
being accidentally left inside a patient’s body during thyroid surgery
and orthopedic procedures, especially hip surgeries. If those are of
interest to you, in addition to the abdominal pain case reports, I can
provide them to you as well. I chose the following case reports to
better answer your question asking specifically about abdominal pain
due to retained surgical sponges, but again, if you are interested in
the others, I would be more than happy to provide them to you. If you
are a foreign language enthusiast you will be pleased, since case
reports involving retained surgical sponges can be found from Turkey
to Pakistan to Taiwan to Mexico and beyond. I think that this list of
case reports and information will be helpful to you. Every link that
corresponds to a case study will take you directly to that case study
with its accompanying information and/or pictures.
http://www.wordspy.com/words/gossypiboma.asp
A gossypiboma is defined as “a surgical sponge accidentally left
inside a patient's body.” It is derived from the Latin “gossypium”
meaning “cotton”, and the Swahili “boma” meaning “place of
concealment.” Synonyms include “textiloma” (a textile “oma” or tumor)
and “retained surgical sponge,” thought by some to be a euphemistic
term. Thanks to my esteemed colleague pafalafa-ga for his assistance
in directing my research on this topic.
http://www.ahcpr.gov/clinic/ptsafety/chap22.htm
This article discusses gossypiboma and the need to count sponges,
sharps and instruments following surgical procedures. It references a
number of articles on this subject, mostly regarding the prevalence of
the problem. One source cites the prevalence as ranging from 1/100 to
1/5000 with associated 11 to 35 percent mortality. It also confirms
that there are relatively few studies relating to gossypiboma and a
handful of case reports, mostly from foreign medical sources. It is an
interesting place to start for some background information.
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http://www.healthcarewatch.net/articles/surgical_errors_alleged_at_stanford_hospital.htm
Here is a news article from The Mercury News that discusses 2 lawsuits
filed against Stanford University in 2002. It also presents a brief
discussion of some of the issues surrounding retained surgical
instruments including sponges.
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http://www.rcsed.ac.uk/journal/vol43_6/4360016.htm
“The Journal of the Royal College of Surgery of Edinburough” describes
a case where a retained sponge presented as a chronic abdominal mass
with associated pain. This is by far the most referenced case report
that I have seen in my research.
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http://www2.mmh.org.tw/gi/papers/gossy.htm
There is a discussion in a Taiwanese journal article that presents 11
cases of gossypiboma from 1982 to 1996. The abstract is presented in
English, but the rest of the web content in displayed in Chinese text.
I have contacted the authors seeking to procure this information and
am awaiting a response from them. I will be sure to post their
response when I receive it.
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http://www.kfshrc.edu.sa/annals/211_212/00-199.PDF
Here is a case report of abdominal swelling and pain without fever
over a three-year period. Pertinent past history includes abdominal
surgery following a traffic accident 9 years prior.
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http://www.jradiology.com/arts/50.pdf
This is a case report of a gossypiboma following resection of the
small bowel. This 30-year-old male presented 3 months later with acute
abdominal symptoms including pain, nausea and vomiting.
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http://www.ijri.org/articles/archives/2002-12-4/abdominal_503.htm
This case report is from a 60-year-old woman presenting 18 days after
total abdominal hysterectomy with abdominal pain. It is from the
Indian Journal of Radiologic Imaging.
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http://www.medigraphic.com/pdfs/endosco/ce-2002/ce024f.pdf
This is a case report from the Mexican Association of Endoscopic
Surgeons. It presents a case of abdominal pain 5 years post Cesarean
section in a 34-year-old patient. The abstract is presented in both
Spanish and English and the article is presented in Spanish only.
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http://www.semes.org/semes_revista_html/revista/vol13_4/291-298.pdf
If you are a Spanish language reader there is a case report of a
gossypiboma given on the last page of this article. This is a case of
a 39-year old who 15 days after an appendectomy develops epigastric
pain and change in bowel habits.
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http://www.kkto.org.tr/geneltip/html/Arsiv/8_2/unutulmus.htm
This is a case report of a 31-year-old female who presented with left
upper quadrant pain 6 years after partial gastrectomy. The brief
summary of the case is included in English and the remainder of the
article is in Turkish.
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http://www.biomedcentral.com/1471-2482/3/6
Here is a case report and discussion from Turkey involving a
74-year-old woman who developed symptoms of small bowel obstruction 3
years after a cholecystectomy.
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http://www.excerptahk.com/jmu/8_4abstract.html##abstract8
This is a case report from the Journal of Medical Ultrasonography.
According to the abstract “the time between implantation of the
surgical sponge and the appearance of symptoms in this case is the
longest ever reported.”
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http://www.webmm.ahrq.gov/cases.aspx?ic=27
This is from Morbidity and Mortality on the Web, and discusses the
potential dangers in gossypiboma.
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http://www.npsf.org/biblio/codesSURe.htm
The National Patient Safety Foundation references the following
article in the New England Journal of Medicine discussion risk factors
for and results from retained surgical sponges:
Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors
for retained instruments and sponges after surgery. “N Engl J Med.”
2003; 348(3): 229-235.
If you have a subscription to the New England Journal, or are willing
to pay for the article, it is available at:
http://content.nejm.org/cgi/content/full/348/3/229. My husband has a
subscription to Uptodate.com where he was able to obtain the abstract
to this article. I’ve included it here for your information.
BACKGROUND: Risk factors for medical errors remain poorly understood.
We performed a case-control study of retained foreign bodies in
surgical patients in order to identify risk factors for this type of
error. METHODS: We reviewed the medical records associated with all
claims or incident reports of a retained surgical sponge or instrument
filed between 1985 and 2001 with a large malpractice insurer
representing one third of the physicians in Massachusetts. For each
case, we identified an average of four randomly selected controls who
underwent the same type of operation during the same six-month period.
RESULTS: Our study included 54 patients with a total of 61 retained
foreign bodies (of which 69 percent were sponges and 31 percent
instruments) and 235 control patients. Thirty-seven of the patients
with retained foreign bodies (69 percent) required reoperation, and
one died. Patients with retained foreign bodies were more likely than
controls to have had emergency surgery (33 percent vs. 7 percent,
P<0.001) or an unexpected change in surgical procedure (34 percent vs.
9 percent, P<0.001). Patients with retained foreign bodies also had a
higher mean body-mass index and were less likely to have had counts of
sponges and instruments performed. In multivariate analysis, factors
associated with a significantly increased risk of retention of a
foreign body were emergency surgery (risk ratio, 8.8 [95 percent
confidence interval, 2.4 to 31.9]), unplanned change in the operation
(risk ratio, 4.1 [95 percent confidence interval, 1.4 to 12.4]), and
body-mass index (risk ratio for each one-unit increment, 1.1 [95
percent confidence interval, 1.0 to 1.2]). CONCLUSIONS: The risk of
retention of a foreign body after surgery significantly increases in
emergencies, with unplanned changes in procedure, and with higher
body-mass index. Case--control analysis of medical-malpractice claims
may identify and quantify risk factors for specific types of errors.
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http://www.kjronline.org/abstract/view_articletext.asp?year=2001&page=87
This article from the Korean Journal of Radiology discusses various
foreign bodies, and specifically includes radiographs of gossypiboma.
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http://www.springerlink.com/app/home/contribution.asp?wasp=lp3ef11a5j7unjac1nby&referrer=parent&backto=issue,10,23;journal,7,87;linkingpublicationresults,id:100483,1
This is a brief description of a recent article in Pediatric Radiology
that discusses colonoscopy as a means to remove a gossypiboma.
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This has been interesting (and a bit unnerving!) research for me.
Clearly, there is a wealth of information available on this topic. As
I said earlier, I am awaiting a response regarding one case report in
particular and will make any new information available to you as soon
as I obtain it. Should you need any further clarification, please do
not hesitate to let me know. Again, thank you for a very interesting
question.
Sincerely,
Boquinha-ga
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Google Search Strategy:
Gossypiboma
://www.google.com/search?sourceid=navclient&ie=UTF-8&oe=UTF-8&q=gossypiboma
gossypiboma abdominal pain
://www.google.com/search?sourceid=navclient&ie=UTF-8&oe=UTF-8&q=gossypiboma+abdominal+pain
gossypiboma case report
://www.google.com/search?sourceid=navclient&ie=UTF-8&oe=UTF-8&q=gossypiboma+case+report
case report retained surgical sponge
://www.google.com/search?sourceid=navclient&ie=UTF-8&oe=UTF-8&q=case+report+retained+surgical+sponge |
Clarification of Answer by
boquinha-ga
on
16 Oct 2003 07:04 PDT
Dr. Free,
I have been hard at work on your two additional questions and have
elected to post the information I have found regarding the pain
pathways at this time.
- - - - - - - - - - - - - - - - - - - -
The following reference from the Indian Journal of Radiologic Imaging,
which is actually a letter regarding a case I previously supplied,
suggests that pain due gossypipoma is a result of either an acute
inflammatory reaction secondary to infection, or possibly due to
pressure effect similar to that of other abdominal masses such as
tumor.
http://www.ijri.org/articles/archives/20001003/letter02.htm
“A retained sponge in the abdominal cavity, in most cases, stimulates
an aseptic inflammatory reaction causing adhesions, fibrosis and a
capsule formation. In most instances, it causes no symptoms.
Occasionally the process in organized, and it may become an abdominal
mass. In some cases, because of secondary infection, an abscess is
formed which is associated with local tenderness and fever, leading to
early diagnosis.
The mass due to the retained sponge may cause pressure effect on the
adjacent organs.”
I searched for specific pain pathways involved in gossypiboma and
found references to the general visceral and somatic pain pathways
involved in abdominal pain. The following description of visceral pain
pathways is a paraphrase from one of my husband’s medical texts
(“Fundamental Neuroscience.” Duane E. Hines, Editor. Churchill
Livingstone: New York. pp. 255-63). Viscerosensory receptors sense
various types of pain (distention, pressure changes, thermal changes,
etc.) and relay that information via afferent sympathetic and
parasympathetic nerve fibers. The afferent sympathetic fibers enter
the spinal column via the lateral division of the dorsal root and have
cell bodies located in the dorsal root ganglia at spinal levels T1 to
L2. These cells then synapse with ascending pathways in the
Anterolateral system. These fibers then proceed either directly to the
thalamus, or indirectly to the thalamus via a multisynaptic pathway
through the reticular formation. From the thalamus, pain signals are
then sent on to various areas in the cerebral cortex.
Parasympathetic afferent fibers pass through the ventral root and
their cell bodies are located in the dorsal root ganglia at the S2 to
S4 spinal levels. They then synapse in the dorsal horn and relay
information in a similar fashion to sympathetic nerves.
- - - - - - - - - - - - - - - - - - - -
I am still searching for the answer to your second question regarding
persistent pain despite removal of the gossypiboma. I will post the
answer once I have obtained one for you.
Sincerely,
Boquinha-ga
- - - - - - - - - - - - - - - - - - - -
Additional Search Terms
pain cause gossypiboma
://www.google.com/search?sourceid=navclient&ie=UTF-8&oe=UTF-8&q=pain+cause+gossypiboma
pain pathway gossypiboma
no results
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Clarification of Answer by
boquinha-ga
on
18 Oct 2003 21:05 PDT
Dr. Free,
As promised, I have been researching your additional questions. I have
already posted the answer to your first additional question and can
now, after additional investigation, respond to your second additional
question. With regard to pain persisting after removal of a
gossypiboma, searches using Google, Pubmed, and various medical
journals turned up limited information. As I have indicated as part of
the original answer, there is a plethora of information available on
gossypiboma and abdominal pain, but nothing discussing persistent
abdominal pain after removal of a gossypiboma. I revisited my original
research and found numerous references discussing abdominal pain
leading up to a diagnosis of gossypiboma, but no case reports
discussing persistent pain despite removal. I also visited the local
medical library and consulted with professionals on this topic. My
research confirms what you have already discovered—there is little to
no information readily available regarding chronic abdominal pain
following the removal of a retained surgical towel.
I have come up, instead, with 2 suggestions. Please keep in mind the
disclaimer found at the bottom of this page that these answers do not
substitute for professional medical advice. Of course, being a
physician yourself, you can, I’m sure, appreciate that. My first
suggestion is that you may want to begin to consider other causes that
may be responsible for your patient’s abdominal pain. My second
suggestion is that this may be an “index case.” In other words, you
may wish to write up your own case report discussing this particular
patient and submit it to the medical community for both publication
and feedback. That could be a very exciting and fascinating venture!
Thank you, again, for a very interesting and challenging question!
Best wishes to you as you delve further into this enigmatic case!
Sincerely,
Boquinha-ga
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